maryland preferred drug list - Provider Synergies

Maryland Medicaid Preferred Drug List EFFECTIVE DATE: 7/1/17

Only drugs that are part of the listed therapeutic categories are affected by the Maryland Medicaid Preferred Drug List (PDL). Therapeutic categories not listed here are not part of the PDL and will continue to be covered as they always have for Maryland Medicaid patients. Note: Brand names listed in parentheses are only listed as a reference. For most multi-source products, the generic products are usually preferred and the branded innovator product is non-preferred. If a generic product is non-preferred, the corresponding brand product is also non-preferred except where specifically noted as “(generic only)”. PDL products that are new to market require prior authorization until they are reviewed.

ANALGESICS Drug Class Analgesics, Narcotics (Long Acting)

Preferred fentanyl patches (Duragesic) (All strengths except 37.5 mcg, 62.5 mcg, and 87.5 mcg) cc,ql morphine sulfate SR (MS Contin)ql Embeda

Analgesics, Narcotics (Short Acting) apap w/codeine (Tylenol w/codeine)ql butalbital/apap/codeine/caffeineql butalbital/aspirin/codeine/caffeineql codeine tablets hydrocodone/apap tablets (Vicodin)ql hydrocodone/ibuprofen (Vicoprofen) hydromorphone tablets (Dilaudid) morphine sulfate tablets, solution oxycodone capsules, tablets, solution oxycodone/apap (Percocet)ql tramadol (Ultram)ql tramadol/apap (Ultracet)ql

Key: cc-Clinical criteria can be found at the link here ql- Quantity limits can be found at the link here All lowercase letters = generic product. Leading capital letter = brand name product.

Requires Prior Authorization fentanyl 37.5 mcg, 62.5 mcg, and 87.5 mcg patchescc,ql hydromorphone ER (Exalgo)ql methadone (Dolophine)ql morphine sulfate ER (Avinza)ql morphine sulfate ER (Kadian)ql oxymorphone ER (Opana ER)ql tramadol ER (Conzip, Ryzolt, Ultram ER)ql Arymo ER Belbucaql Butransql Hysingla ERcc,ql Nucynta ERql Oxycontinql Xtampza ER Zohydro ERcc,ql butorphanol nasal spray carisoprodol/codeine/asa dihydrocodeine/aspirin/caffeine (Synalgos DC) fentanyl buccal (Actiq)cc,ql hydrocodone/apap solution hydromorphone suppositories and solution levorphanol meperidine (Demerol) morphine suppositories oxycodone concentrated solution oxycodone/aspirin (Percodan) oxycodone/ibuprofen (Combunox) oxymorphone (Opana) pentazocine/naloxone (Talwin NX) Abstralcc,ql Fentoracc,ql Lazandacc,ql Nucynta Primlevql Subsyscc,ql Xartemis XRcc,ql

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ANALGESICS Drug Class

Preferred

Requires Prior Authorization

Anti-Migraine Agents

rizatriptan, rizatriptan ODT (Maxalt, Maxalt MLT)ql sumatriptan nasal, syringe, tablets (Imitrex)ql Relpaxql

almotriptan (Axert)ql naratriptan (Amerge)ql sumatriptan kit, vial (Imitrex)ql zolmitriptan, zolmitriptan ODT (Zomig, Zomig ZMT)ql Frovaql Migranow Kit Onzetra Xsail Sumavel Treximetql Zecuityql Zembrace Symtouch Zomig nasalql

Neuropathic Pain

capsaicin OTC duloxetine (Cymbalta)cc,ql gabapentin capsules gabapentin tablets lidocaine patch Lyrica capsulesql

gabapentin solution DermacinRx PHN Pak Gralise Horizant Irenkaql Lyrica solution Neurontin Qutenza Kit Savella

Nonsteroidal Anti-Inflammatories (NSAIDS)

diclofenac, diclofenac XL (Cataflam, Voltaren XR) diflunisal (Dolobid) etodolac, etodolac XL (Lodine, Lodine XL) fenoprofen flurbiprofen (Ansaid) ibuprofen Rx and OTC (Motrin) indomethacin, indomethacin SR (Indocin, Indocin SR) ketoprofen, ketoprofen ER (Orudis, Oruvail) ketorolac (Toradol) meclofenamate (Meclomen) meloxicam (Mobic) nabumetone (Relafen) naproxen Rx and OTC (Aleve, Naprosyn) oxaprozin (Daypro) piroxicam (Feldene) sulindac (Clinoril) Voltaren gel

celecoxib (Celebrex) diclofenac solution (Pennsaid) diclofenac/misoprostol (Arthrotec) mefenamic acid (Ponstel) tolmetin, tolmetin DS (Tolectin, Tolectin DS) Dermacinrx Lexitral Duexis Flector Indocin suppositories and suspension Sprix Tivorbex Vimovo Vivlodex Vopac MDS Xrylix Kit Zipsor Zorvolex

Opiate Dependence Treatments

buprenorphine (Subutex)cc,ql naloxone (Narcan) naltrexone (Revia)cc Bunavailql Narcan nasal spray Suboxone filmql Vivitrolcc,ql Zubsolvql

buprenorphine/naloxone tablets (Suboxone)ql


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ANALGESICS Drug Class Skeletal Muscle Relaxants

Preferred baclofen (Lioresal) chlorzoxazone (Parafon) cyclobenzaprine (Flexeril) methocarbamol (Robaxin) orphenadrine (Norflex) tizanidine tablets (Zanaflex)

Requires Prior Authorization carisoprodol 250mg (Soma) carisoprodol 350mg (Soma) carisoprodol compound (Soma Compound) dantrolene (Dantrium) metaxalone (Skelaxin) tizanidine capsules (Zanaflex) Amrix Lorzone

ANTI-INFECTIVES Drug Class

Preferred


Antibiotics, GI

metronidazole tablets (Flagyl) neomycin vancomycin capsules (Vancocin) Alinia suspension

metronidazole capsules (Flagyl capsules) paromomycin tinidazole (Tindamax) Alinia tablet Dificidcc,ql Flagyl ER Xifaxancc,ql

Antibiotics, Inhaled

Bethkiscc,ql Kitabis Pak(Brand only)cc ql Tobi Podhaler (Step therapy) cc,ql

tobramycin inhalation solution (Tobi)cc,ql tobramycin pak (Kitabis) (generic only)cc,ql Caystoncc,ql

Antibiotics, Topical

bacitracin OTC bacitracin/polymyxin OTC gentamicin mupirocin ointment (Bactroban Ointment) triple antibiotic OTC

mupirocin cream (Bactroban Cream) Altabax Centany

Antibiotics, Vaginal

clindamycin (Cleocin) metronidazole vaginal (Metrogel) Clindesse Cleocin ovule

Nuvessa Vandazole

Antifungals, Oral

clotrimazole troches (Mycelex) fluconazole (Diflucan) griseofulvin suspension (GriFulvin V) ketoconazole (Nizoral) nystatin suspension and tablets terbinafine (Lamisil)

flucytosine (Ancobon) griseofulvin tablets (Gris Peg, GriFulvin V) itraconazole (Sporanox) voriconazole (Vfend) Cresemba Lamisil granules Noxafil Onmel Oravig Terbinex


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ANTI-INFECTIVES Drug Class

Preferred


Antifungals, Topical

clotrimazole Rx and OTC clotrimazole/betamethasone cream (Lotrisone) ketoconazole cream and shampoo (Nizoral) miconazole cream OTC nystatin nystatin/triamcinolone (Mycolog) terbinafine OTC tolnaftate OTC

ciclopirox (Loprox,Loprox Kit,Loprox Shampoo,Penlac) clotrimazole/betamethasone lotion (Lotrisone) econazole (Spectazole) ketoconazole foam (Ketodan) miconazole ointment, powder, spray OTC naftifine (Naftin) Bensal HP CNL-8 DermacinRx Therazole Pak Desenex spray powder Ertaczo Exelderm Fungoid OTC Jublia Kerydin Lamisil OTC Lotrimin AF Luzucc,ql Oxistat Pediaderm AF Vusion

Antiparasitics, Topical

permethrin Rx and OTC (Elimite, Acticin) piperonyl/pyrethrins OTC piperonyl/pyrethrins/permethrin OTC

lindane shampoo malathion (Ovide) spinosad (Natroba) Eurax Sklicecc,ql Ulesfia

Antivirals, Oral

acyclovir (Zovirax) valacyclovir (Valtrex)

famciclovir (Famvir) oseltamivir (Tamifu) rimantadine (Flumadine) Relenza Sitavig

Antivirals, Topical

Abreva OTC Zovirax cream

acyclovir ointment (Zovirax ointment) Denavir Xerese

Cephalosporin and Related Agents

amoxicillin/clavulanate (Augmentin, Augmentin ES) cefaclor capsules (Ceclor) cefadroxil capsules (Duricef) cefdinir (Omnicef) cefixime suspension (Suprax) cefprozil (Cefzil) cefuroxime tablets (Ceftin) cephalexin (Keflex) Suprax capsules

amoxicillin/clavulanate ER (Augmentin XR) cefaclor suspension, tablets ER (Ceclor, Ceclor CD) cefadroxil suspension and tablets (Duricef) cefpodoxime (Vantin) ceftibuten (Cedax) Ceftin suspension Suprax tablets

Fluoroquinolones

ciprofloxacin tablets (Cipro) levofloxacin tablets (Levaquin)

ciprofloxacin ER (Cipro XR) ciprofloxacin suspension (Cipro) levofloxacin solution (Levaquin) moxifloxacin (Avelox) ofloxacin (Floxin)


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ANTI-INFECTIVES Drug Class Hepatitis B Agents

Preferred entecavir (Baraclude) lamivudine HBV (Epivir HBV)

Requires Prior Authorization adefovir (Hepsera) (generic only) Vemlidy

Hepsera (Brand only) Hepatitis C Agents

ribavirin (Copegus, Rebetol) Epclusacc Harvonicc Pegasys PegIntron Techniviecc Viekira Pakcc Viekira XRcc Zepatiercc

Daklinzacc Moderiba Olysiocc Rebetol solution Ribapak Ribasphere Sovaldicc

Macrolides/Ketolides

azithromycin (Zithromax) clarithromycin tablets (Biaxin) erythromycin base capsule DR E.E.S. EryPed (Brand Only) Ery-Tab Erythrocin

clarithromycin suspension (Biaxin) clarithromycin ER (Biaxin XL) erythromycin base tablet erythromycin ethyl succinate granules for suspension (generic only) Ketek PCE Zmax

Tetracyclines

doxycycline hyclate (Vibramycin) doxycycline monohydrate 50mg, 100mg (Monodox) minocycline capsules (Minocin) tetracycline (Sumycin)

demeclocycline (Declomycin) doxycycline hyclate DR (Doryx, Doryx MPC) doxycycline monohydrate 40mg, 75mg, 150mg (Oracea, Monodox, Adoxa) doxycycline monohydrate suspension (Vibramycin) minocycline tablets minocycline ER (Solodyn) Vibramycin syrup

BLOOD MODIFIERS Drug Class

Preferred


Anti-Hyperuricemics

allopurinol (Zyloprim) probenecid probenecid/colchicine

colchicine (Colcrys) Mitigare Uloric Zurampic

Colony Stimulating Factors

Granix Neupogen

Leukine Neulasta

Erythropoietins

Aranesp Procrit

Epogen Mircera

Phosphate Binders and Related Agents

calcium acetate (PhosLo) calphron OTC

Auryxia Fosrenol Magnebind 400 Rx Phoslyra Renagel Renvela Velphoro


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CARDIOVASCULAR Drug Class

Preferred


Angiotensin Modulator Combinations

amlodipine/benazepril (Lotrel) amlodipine/valsartan (Exforge) amlodipine/valsartan/HCTZ (Exforge HCT)

amlodipine/olmesartan (Azor) amlodipine/olmesartan/HCTZ (Tribenzor) telmisartan/amlodipine (Twynsta) trandolapril/verapamil (Tarka) Tekamlo/Amturnide Byvalson Prestalia

Angiotensin Modulators

benazepril, benazepril/HCTZ (Lotensin, Lotensin HCT) enalapril, enalapril/HCTZ (Vasotec, Vaseretic) irbesartan, irbesartan/HCTZ (Avapro, Avalide) lisinopril, lisinopril/HCTZ (Prinivil, Zestril, Prinzide, Zestoretic) losartan, losartan/HCTZ (Cozaar, Hyzaar) quinapril, quinapril/HCTZ (Accupril, Accuretic) ramipril (Altace) valsartan, valsartan/HCTZ (Diovan, Diovan HCT) Entrestocc,ql

candesartan, candesartan/HCTZ (Atacand, Atacand HCT) captopril captopril/HCTZ (Capozide) eprosartan (Teveten) fosinopril, fosinopril/HCTZ (Monopril, Monopril HCT) moexipril, moexipril/HCTZ (Univasc, Uniretic) olmesartan, olmesartan/HCTZ (Benicar, Benicar HCT) perindopril (Aceon) telmisartan, telmisartan/HCTZ (Micardis, Micardis HCT) trandolapril (Mavik) Edarbi, Edarbyclor Epaned solution Tekturna, Tekturna HCT Qbrelis

Anticoagulants

enoxaparin (Lovenox)ql warfarin (Coumadin) Eliquis Fragminql Xarelto

fondaparinux (Arixtra)ql Pradaxaql Savaysa Xarelto Dose Pack

Antihypertensives, Sympatholytics

clonidine oral (Catapres) guanfacine (Tenex) methyldopa (Aldomet) methyldopa/HCTZ (Aldoril) Catapres TTS (Brand only)ql

clonidine patch (generic only)ql reserpine Clorpres

Beta Blockers

atenolol, atenolol/chlorthalidone (Tenormin, Tenoretic) bisoprolol/HCTZ (Ziac) carvedilol (Coreg) labetalol (Normodyne, Trandate) metoprolol tartrate (Lopressor) metoprolol succinate XL (Toprol XL) pindolol (Visken) propranolol, propranolol/HCTZ (Inderal, Inderide) propranolol LA (Inderal LA) sotalol, sotalol AF (Betapace, Betapace AF)

acebutolol (Sectral) betaxolol (Kerlone) bisoprolol (Zebeta) metoprolol/HCTZ (Lopressor HCT) nadolol (Corgard) nadolol/bendroflumethiazide (Corzide) timolol (Blocadren) Bystolic Coreg CR Dutoprol Hemangeol Levatol Sotylize


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CARDIOVASCULAR Drug Class

Preferred


Calcium Channel Blocking Agents

amlodipine (Norvasc) diltiazem (Cardizem) diltiazem ER capsules (Cardizem CD, Tiazac) nicardipine (Cardene) nifedipine (Adalat, Procardia) nifedipine ER (Adalat CC, Procardia XL) verapamil (Calan) verapamil ER tablets (Calan SR)

diltiazem ER tablets (Cardizem LA) felodipine (Plendil) isradipine (Dynacirc) nimodipine (Nimotop) nisoldipine (Sular) verapamil ER capsules (Verelan, Verelan PM) Nymalize

Lipotropics, Other

colestipol tablet (Colestid) cholestyramine (Questran) fenofibrate nanocrystals (Tricor) fenofibric acid (Trilipix) gemfibrozil (Lopid) niacin ER (Niaspan ER) Niacor

colestipol granules (Colestid) ezetimibe (Zetia) fenofibrate (Antara, Fenoglide, Lipofen, Lofibra) fenofibric acid (Fibricor) omega-3 ethyl esters (Lovaza) Juxtapid Kynamro Praluentcc Repathacc Triglide Vascepa Welchol

Lipotropics, Statins

atorvastatin (Lipitor) lovastatin (Mevacor) pravastatin (Pravachol) rosuvastatin (Crestor) simvastatin (Zocor)

amlodipine/atorvastatin (Caduet) ezetimibe-simvastatin (Vytorin) fluvastatin, fluvastatin ER (Lescol, Lescol XL) Advicor Altoprev Liptruzet Livalo Simcor

Platelet Aggregation Inhibitors

clopidogrel (Plavix)ql dipyridamole (Persantine)ql ticlopidine (Ticlid)

aspirin/dipyridamole (Aggrenox)ql Brilintaql Durlaza Effientql Zontivity

Pulmonary Arterial Hypertension, Oral and Inhaled Agents

sildenafil (Revatio)cc,ql Letairis Tracleer Ventavis

Adcircacc,ql Adempas Opsumit Orenitram ERcc,ql Revatio suspensioncc,ql Tyvasocc Uptravi


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CENTRAL NERVOUS SYSTEM The Mental Health Carve Out can be found at the link here

Drug Class

Preferred


Anticonvulsants

carbamazepine tablets (Tegretol) carbamazepine ER (Carbatrol ER) clonazepam (Klonopin) divalproex, divalproex ER (Depakote, Depakote ER) divalproex sprinkles (Depakote sprinkles) lamotrigine (Lamictal) levetiracetam (Keppra) oxcarbazepine tablets (Trileptal) oxcarbazepine suspension (Trileptal) (Brand and generic) phenobarbital phenytoin, phenytoin ER (Dilantin, Dilantin Infatabs) primidone (Mysoline) topiramate (Topamax) valproic acid (Depakene) zonisamide (Zonegran) Celontin Diastat (Brand only) Gabitril (Brand only) Peganone Tegretol suspension (Brand only)

carbamazepine suspension (Tegretol) (generic only) carbamazepine XR (Tegretol XR) clonazepam ODT (Klonopin ODT) diazepam rectal (Diastat) (generic only) ethosuximide (Zarontin) felbamate (Felbatol) lamotrigine ER (Lamictal XR) lamotrigine ODT (Lamictal ODT) levetiracetam ER (Keppra XR) tiagabine (Gabitril) (generic only) topiramate ER (Qudexy XR)cc,ql topiramate sprinkles (Topamax Sprinkles) Aptiomcc, Banzelcc,ql Briviact Equetro Fycompacc Onficc,ql Oxtellar XR Potiga Sabril Spritam Stavzor Trokendi XR Vimpat

Antidepressants, Other

bupropion, bupropion SR, buproprion XL (Wellbutrin, Wellbutrin SR, Wellbutrin XL) mirtazapine, mirtazapine ODT (Remeron, Remeron Soltab) phenelzine (Nardil) trazodone (Desyrel) venlafaxine (Effexor) venlafaxine ER capsules (Effexor XR) Parnate (Brand only)

desvenlafaxine ER (Khedezla, Pristiq) nefazodone (Serzone) tranylcypromine (generic only) venlafaxine ER tablets Aplenzin Emsam Fetzima Forfivo XL Marplan Oleptro ER Trintellix Viibryd

Antidepressants, Selective Serotonin Reuptake Inhibitors (SSRIs)

citalopram (Celexa)ql escitalopram tablets (Lexapro) fluoxetine capsules (all strengths except 60mg) (Prozac, Sarafem) fluvoxamine (Luvox) paroxetine (Paxil) sertraline (Zoloft)

escitalopram solution (Lexapro) fluoxetine capsules 60mg fluoxetine tablets (all strengths) fluoxetine weekly (Prozac weekly) fluvoxamine ER (Luvox CR) paroxetine CR (Paxil CR) Brisdellecc,ql Paxil suspension Pexeva


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Drug Class

Preferred


Antipsychotics

1st Tier aripiprazole (Abilify) (generic only)cc,ql aripiprazole ODT(Abilify Discmelt (generic only)cc,ql chlorpromazine (Thorazine) clozapine (Clozaril) fluphenazine (Prolixin) fluphenazine decanoate inj (Prolixin Inj.) haloperidol (Haldol) haloperidol decanoate inj (Haldol IM) loxapine capsules (Loxitane) olanzapine IM (Zyprexa IM)cc,ql olanzapine ODT (Zyprexa Zydis)cc,ql olanzapine tablets (Zyprexa)cc,ql perphenazine (Trilafon) perphenazine/amitriptyline (Triavil) quetiapine (Seroquel)cc,ql risperidone, risperidone ODT (Risperdal) cc,ql thioridazine (Mellaril) thiothixene (Navane) trifluoperazine (Stelazine) ziprasidone (Geodon) cc,ql Abilify Maintenaql Geodon IM Invega Sustennaql Invega Trinzacc,ql Orap Risperdal Constaql 2nd Tier Latudacc,ql

clozapine ODT (Fazaclo)cc olanzapine/fluoxetine (Symbyax)cc,ql quetiapine ER (Seroquel XR) cc,ql Adasuvecc, Aristada,cc, ql Fanaptcc,ql Invega tablets (Brand only)cc,ql Nuplazidcc Rexulticc,ql Saphriscc,ql Versaclozcc Vraylarql Zyprexa Relprevvcc,ql

Sedative Hypnotics

flurazepam (Dalmane)ql temazepam 15mg, 30mg (Restoril)ql triazolam (Halcion)ql zaleplon (Sonata)ql zolpidem (Ambien)ql

estazolam (ProSom)ql eszopiclone (Lunesta)cc,ql temazepam 7.5mg, 22.5mg (Restoril)ql zolpidem ER (Ambien CR) Belsomracc,ql Edluarql Hetliozcc,ql Intermezzoql Rozeremql Silenor Zolpimistql


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Drug Class Stimulants and Related Agents

Preferred 1st Tier amphetamine salt combo (Adderall) dextroamphetamine capsules (Dexedrine ER) dextroamphetamine tablets guanfacine ER (Intuniv)cc,ql methylphenidate tablets (Ritalin) methylphenidate ER tablets (Ritalin SR) methylphenidate CD capsules (Metadate CD) methylphenidate CR tablets (Concerta) Adderall XR (Brand only) Daytrana Focalin (Brand only) Focalin XR (Brand only) Kapvay (Brand only) cc,ql Methylin oral solution (Brand only) Quillivant XR Ritalin LA (Brand only) Vyvanse Vyvanse chewable tablets 2nd Tier atomoxetine (Strattera)cc

Requires Prior Authorization amphetamine salt combo ER (Adderall XR) (generic only) armodafinil (Nuvigil)cc,ql clonidine ER (generic only) cc,ql dexmethylphenidate (Focalin) (generic only) dexmethylphenidate XR (Focalin XR) (generic only) dextroamphetamine solution (Procentra) methamphetamine (Desoxyn) methylphenidate ER capsules (Ritalin LA) (generic only) methylphenidate chewable (Methylin chewable) methylphenidate oral solution (Methylin) (generic only) modafinil (Provigil)cc,ql Adzenys XR ODT Aptensio XR Dyanavel XR Evekeo Quillichew ER Zenzedi

ENDOCRINE Drug Class

Preferred


Androgenic Agents

Androderm cc,ql Androgel gel packet and gel pump (Brand only)

testosterone gel packet and gel pump (Androgel) (generic only) testosterone gel (Testim) testosterone gel (Vogelxo) testosterone gel pump (Fortesta) Axiron Natesto

Bone Resorption Suppression and Related Agents

alendronate tablets (Fosamax)ql calcitonin salmon nasal (Miacalcin)ql Forticalql

alendronate solution (Fosamax Solution)ql etidronate (Didronel)ql ibandronate (Boniva)ql raloxifene (Evista)ql risedronate (Atelvia)ql risedronate (Actonel)ql Binostoql Forteocc,ql Fosamax Plus Dql Proliacc,ql

Growth Hormones

Genotropincc Norditropincc Nutropincc, Nutropin AQcc

Humatropecc Omnitropecc Saizencc Serostimcc Zomactoncc Zorbtivecc


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ENDOCRINE Drug Class

Preferred


Hypoglycemics, Incretin Mimetics and Enhancers

Bydureon Byetta Janumet, Janumet XR Januvia Jentadueto Symlin Tradjenta

alogliptin (Nesina) alogliptin/metformin (Kazano) alogliptin/pioglitazone (Oseni) Adlyxin Glyxambicc,ql Jentadueto XR Kombiglyze XR Onglyza Soliqua Tanzeum Trulicity Victozaql Xultophy

Hypoglycemics, Insulins

Humalog cartridge, vial Humalog Mix vial Humulin vial Lantus Levemir NovoLog NovoLog Mix

Afrezza Apidra Basaglar Humalog pen Humalog Mix pen Humulin pen Humulin 70/30 pen Humulin 500unit/mL pen Novolin vial Novolin 70/30 vial Toujeo Tresiba

Hypoglycemics, Meglitinides

nateglinide (Starlix) repaglinide (Prandin)

repaglinide/metformin (Prandimet)

Hypoglycemics, Metformins

glipizide/metformin (Metaglip) glyburide/metformin (Glucovance) metformin (Glucophage) metformin ER (Glucophage XR)

metformin ER (Fortamet) cc,ql metformin ER (Glumetza) cc,ql

Hypoglycemics, SGLT2 Inhibitors

Farxiga (Step Therapy) cc,ql Invokana (Step Therapy) cc,ql

Invokametcc,ql Invokamet XRcc,ql Jardiancecc,ql Synjardycc,ql Xigduo XRcc,ql

Hypoglycemics, TZDs

pioglitazone (Actos)

pioglitazone/glimepiride (Duetact) pioglitazone/metformin (ActoPlusMet) ActoPlusMet XR Avandia, Avandamet, Avandaryl


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GASTROINTESTINAL Drug Class

Preferred


Antiemetic/Antivertigo Agents

meclizine Rx and OTC (Bonine, Antivert) metoclopramide (Reglan) ondansetron, ondansetron ODT (Zofran)ql prochlorperazine oral (Compazine, Compro) promethazine (Phenergan) Emend capsules (Brand only) ql TransDerm-Scop

aprepitant capsules, pack (generic only) dimenhydrinate Rx and OTC dronabinol (Marinol)cc,ql granisetron (Kytril)ql metoclopramide ODT (Metozolv ODT) prochlorperazine rectal (Compro) trimethobenzamide (Tigan) Aloxi Akynzeocc Anzemetql Cesametql Diclegiscc,ql Emend IV Emend pack Emend powder packetsql Sancusoql Sustol Varubi Zuplenz

Bile Salts

ursodiol capsules (Actigall) ursodiol tablets (URSO, URSO Forte)

Chenodal Cholbam Ocaliva

Gastrointestinal Motility, Chronic

Amitiza Linzesscc.ql Movantikcc,ql

alosetron (Lotronex) Relistorcc,ql Trulance Viberzi

Pancreatic Enzymes

Creon Zenpep

Pancreaze Pertzye Ultresa Viokace

Proton Pump Inhibitors

lansoprazole capsules (Prevacid) omeprazole capsules (Prilosec) pantoprazole (Protonix) Nexium packet for suspension Prevacid Solutab Protonix suspension

esomeprazole magnesium (Nexium) lansoprazole OTC omeprazole OTC omeprazole/sodium bicarb (Zegerid) rabeprazole (Aciphex) Aciphex Sprinkle Dexilant Prilosec suspension

Ulcerative Colitis Agents

balsalazide (Colazal) sulfasalazine, sulfasalazine DR (Azulfidine, Azulfidine DR) Apriso Canasa

mesalamine enemas (Rowasa, sfRowasa) Asacol HD Delzicol Dipentum Giazo Lialda Pentasa Uceris


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IMMUNOLOGICS Drug Class

Preferred


Cytokine and CAM Antagonists

Enbrel Humira

Actemra Arcalyst Cimzia Cosentyx Entyvio Ilaris Inflectra Kineret Orencia Otezlacc Remicade Simponi Stelara Taltz Xeljanz Xeljanz XR

Immunosuppressives, Oral

azathioprine (Imuran) cyclosporine (Sandimmune) cyclosporine modified (Gengraf, Neoral) mycophenolic acid (Myfortic) mycophenolate mofetil capsules, tablets (Cellcept) sirolimus (Rapamune) tacrolimus (Prograf) Cellcept suspension (brand only) Rapamune solution Sandimmune solution

mycophenolate mofetil suspension (Cellcept) (generic only) Astagraf XL Azasan Envarsus XR Zortress

NEUROLOGICS Drug Class

Preferred


Alzheimer’s Agents

donepezil, donepezil ODT (all strengths except 23mg) (Aricept, Aricept ODT) memantine (Namenda) rivastigmine capsules, patches (Exelon) ql

donepezil 23mg (Aricept) galantamine, galantamine ER (Razadyne, Razadyne ER) Namenda XR Namzaric and Namzaric dose pack

Anti-Parkinson’s Agents

amantadine (Symmetrel) benztropine (Cogentin) levodopa/carbidopa IR, levodopa/carbidopa ER (Sinemet, Sinemet CR) levodopa/carbidopa/entacapone (Stalevo) pramipexole (Mirapex) ropinirole (Requip) selegiline tablets (Eldepryl) trihexyphenidyl (Artane)

bromocriptine (Parlodel) carbidopa (Lodosyn) entacapone (Comtan) levodopa/carbidopa ODT (Parcopa) pramipexole ER (Mirapex ER) ropinirole ER (Requip XL) rasagiline (Azilect) selegiline capsules (Eldepryl) tolcapone (Tasmar) Duopa Neupro Rytary Zelapar


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NEUROLOGICS Drug Class Multiple Sclerosis Agents

Preferred Avonex Betaseron Copaxone 20mg (Brand only) Rebif

Requires Prior Authorization glatiramer acetate 20mg (Glatopa) (generic only) Ampyracc,ql Aubagiocc,ql Copaxone 40mg Extavia Gilenyacc,ql Lemtradacc Plegridycc Tecfideracc,ql Zinbryta

OPHTHALMICS Drug Class

Preferred


Ophthalmics, Allergic Conjunctivitis cromolyn (Crolom) ketotifen OTC (Zaditor OTC) Alrex Pataday Pazeo

azelastine (Optivar) epinastine (Elestat) Alocril Alomide Bepreve Emadine Lastacaft Patanol

Ophthalmics, Antibiotics

bacitracin/polymixin ciprofloxacin solution (Ciloxan) erythromycin gentamicin (Garamycin) neomycin/polymixin/gramicidin (Neosporin) ofloxacin (Ocuflox) polymyxin/trimethoprim (Polytrim) sulfacetamide solution (Bleph-10) tobramycin (Tobrex Drops) Ciloxan ointment Moxeza Tobrex ointment Vigamox

bacitracin gatifloxacin (Zymaxid) levofloxacin (Quixin) sulfacetamide ointment AzaSite Besivance Natacyn

Ophthalmics, Antibiotic/Steroid Combinations

neomycin/poly/dexamethasone (Maxitrol) sulfacetamide/prednisolone tobramycin/dexamethasone drops (Tobradex) Tobradex ointment

neomycin/bacitracin/polymyxin/HC neomycin/polymyxin/HC Blephamide, Blephamide S.O.P. Pred-G Tobradex ST Zylet


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OPHTHALMICS Drug Class

Preferred


Ophthalmics, Glaucoma Agents

brimonidine (Alphagan P 0.1%) carteolol (Ocupress) dorzolamide (Trusopt) dorzolamide/timolol (Cosopt) latanoprost (Xalatan) levobunolol (Betagan) metipranolol (OptiPranolol) pilocarpine (Pilocar) timolol (Timoptic, Timoptic XE) Alphagan P 0.15% (Brand only) Azopt Betimol Combigan Simbrinza Travatan Z

apraclonidine (Iopidine) betaxolol bimatoprost 0.03% (Lumigan) brimonidine 0.15% (Alphagan P) (generic only) travoprost Betoptic S Cosopt PF Istalol Lumigan 0.01% Zioptan

Ophthalmics, Anti-Inflammatories

dexamethasone (Decadron) diclofenac (Voltaren) fluorometholone (FML) flurbiprofen (Ocufen) ketorolac (Acular) ketorolac LS (Acular LS) prednisolone acetate (Omnipred) Durezol Flarex FML SOP Ilevro Lotemax drops Maxidex Pred Mild

bromfenac (Xibrom) prednisolone sodium (Pred Forte) Acuvail Bromsite FML Forte Iluvien Lotemax ointment and gel Nevanac Ozurdex Prolensa Retisert Triesence Vexol

Ophthalmics, AntiInflammatory/Immunomodulator

Restasis single-use

Restasis multidose Xiidra

OTIC Drug Class Otic Antibiotics

Preferred neomycin/polymyxin/HC (Cortisporin) ofloxacin otic (Floxin Otic) Ciprodex

Requires Prior Authorization ciprofloxacin Cipro HC Coly-Mycin S Otiprio Otovel

RESPIRATORY Drug Class Antihistamines, Minimally Sedating

Preferred cetirizine, cetirizine D Rx and OTC (Zyrtec, Zyrtec D) fexofenadine OTC (Allegra) levocetirizine tablets (Xyzal) loratadine, loratadine D, loratadine ODT Rx and OTC (Claritin, Claritin D)


Requires Prior Authorization desloratadine, desloratadine D, desloratadine ODT (Clarinex, Clarinex D, Clarinex RDT) fexofenadine Rx (Allegra) fexofenadine D (Allegra D) levocetirizine solution (Xyzal) Semprex D

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RESPIRATORY Drug Class

Preferred


Bronchodilators, Beta Agonists

albuterol neb 0.083% and 5mg/ml albuterol neb 0.63mg/3ml and 1.25mg/3ml (AccuNeb) albuterol syrup and tablets (Proventil, Ventolin) terbutaline (Brethine) Foradil ProAir HFAql Proventil HFAql Serevent

albuterol ER (Vospire ER) levalbuterol (Xopenex) levalbuterol HFA (Xopenex HFA)ql metaproterenol (Alupent) Arcapta Brovana Perforomist ProAir Respiclickql Striverdi Respimat Ventolin HFAql

COPD Agents

ipratropium neb (Atrovent) ipratropium/albuterol neb (DuoNeb) Atrovent HFA Combivent Respimatql Spiriva

Anoro Ellipta Bevespi Aerosphere Daliresp Incruse Ellipta Seebri Neohaler Spiriva Respimat Stiolto Respimat Tudorza Utibron Neohaler

Glucocorticoids, Inhaled

Advair Diskus, Advair HFA Asmanex Dulera Pulmicort Respules, 0.25mg , 0.5mg and 1mg (Brand only) QVAR Symbicort

budesonide inhalation susp. (generic only) Aerospan Alvesco Arnuity Ellipta Asmanex HFA Breo Ellipta Flovent Diskus, Flovent HFA Pulmicort Flexhalerql

Intranasal Rhinitis Agents

azelastine nasal (Astelin) fluticasone nasal (Flonase) ipratropium (Atrovent Nasal)

azelastine nasal (Astepro) budesonide nasal (Rhinocort Aqua) flunisolide (Nasarel, Nasalide) fluticasone (Ticanase) mometasone nasal (Nasonex) olopatadine (Patanase) triamcinolone nasal (Nasacort AQ) Beconase AQ Flonase OTC Dymista Omnaris Qnasl Veramyst Zetonna

Leukotriene Modifiers

montelukast chewables and tablets (Singulair) zafirlukast (Accolate)

montelukast granules (Singulair Granules) Zyflo, Zyflo CR


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TOPICAL DERMATOLOGICS Drug Class

Preferred


Acne Agents, Topical

benzoyl peroxide OTC erythromycin/benzoyl peroxide clindamycin (all forms except the foam) erythromycin tretinoin (Avita, Retin-A)cc Azelex Differin cream (Brand only) cc Differin lotioncc

adapalene cream (Differin cream) (generic only) cc adapalene gel (Differin gel)cc benzoyl peroxide Rx bp-10-1 clindamycin foam clindamycin/benzoyl peroxide clindamycin/tretinoin (Veltin) sulfacetamide sulfacetamide/sulfur sulfacetamide/sulfur/urea tazarotene (Tazorac)cc tretinoin micro (Retin-A Micro)cc Acanya Aczone Gel and Gel w/Pump Akne-Mycin Atralin Avar BenzaClin Benzamycin Clindacin Epiduo Epiduo Forte Gel w/Pump Fabior Neuac Onexton Ovace Sumaxin CP Kit Ziana

Immunomodulators, Atopic Dermatitis

Elidel

tacrolimus ointment (Protopic) Eucrisa

UROLOGIC Drug Class

Preferred


Benign Prostatic Hyperplasia

alfuzosin (Uroxatral) doxazosin (Cardura) dutasteride (Avodart) finasteride (Proscar) tamsulosin (Flomax) terazosin (Hytrin)

dutasteride/tamsulosin (Jalyn) Cardura XL Rapaflo

Bladder Relaxant Preparations

oxybutynin, oxybutynin ER (Ditropan, Ditropan XL) Toviaz

flavoxate tolterodine, tolterodine ER (Detrol, Detrol LA) trospium, trospium ER (Sanctura, Sanctura XR) Enablex Gelnique Myrbetriq Oxytrol Vesicare


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